School Lunch Allergy Declaration Form
Student Name
Grade/Class
Date of Birth
Parent/Guardian Name
Contact Number
Allergy Information
List all known food allergies
Type of Allergic Reaction (select all that apply)
Rash/hives
Swelling
Breathing problems
Anaphylaxis
Other
If other, please specify
Treatment Instructions (e.g., medication, epinephrine, etc.)
Additional Notes